| Abstract|| |
Chronic kidney disease (CKD) patients are at high risk of depressive disorders because of considerable psychological stress due to physical and social changes brought on by disease. The aim of this study is to assess the prevalence of depression in patients with CKD and the factors affecting it at a public tertiary care hospital. This cross-sectional study was carried out at the renal clinic of a tertiary care hospital. Data on 612 patients diagnosed with CKD from September 2014 to April 2016 was obtained. Nine-item Patient Health Questionnaire from PRIME-MD was used to assess the depression. Of all the patients, 55.9% had no depression. Mild depression was found to affect 28.4% of the patients followed by moderate depression, moderately severe, and severe depression (11.8%, 3.8%, and 0.8%, respectively). According to multiple logistic regression, the occurrence of depression was significantly higher with age below 60 years [odds ratio (OR) 1.6, 0.8–2.7; P<0.05], male gender (OR 1.3, 0.9–3.1; P<0.05), no treatment funding (OR 2.6, 1.2–4.5; P<0.05), education less than grade 12 (OR1.3, 1.3–3.2; P<0.05), monthly income ≤INR 20,000 (OR 1.6, 1.1–3.6; P<0.05), CKD stage V (OR 1.3, 1.02.9; P <0.05), Patients on hemodialysis (hD) (OR 2.6, 1.2–4.5; P<0.05), comorbidities ≥3 (OR 1.7, 1.1–2.9; P<0.05), overweight (OR 2.5, 1.3–2.9; P<0.05), and duration of CKD >2 (OR 2.2, 1.3–4.3; P<0.05). About 44% of the patients were found to have depression. Patients’ age, gender, body mass index, treatment funding, education status, income, CKD duration and stage, HD status, and comorbidities were found to be significant factors affecting depression.
|How to cite this article:|
Ahlawat R, Tiwari P, D'Cruz S. Prevalence of depression and its associated factors among patients of chronic kidney disease in a public tertiary care hospital in India: A cross-sectional study. Saudi J Kidney Dis Transpl 2018;29:1165-73
|How to cite this URL:|
Ahlawat R, Tiwari P, D'Cruz S. Prevalence of depression and its associated factors among patients of chronic kidney disease in a public tertiary care hospital in India: A cross-sectional study. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2018 Dec 15];29:1165-73. Available from: http://www.sjkdt.org/text.asp?2018/29/5/1165/243972
| Introduction|| |
Chronic kidney disease (CKD) is one of the major chronic noncommunicable health problems in India. According to the findings of screening and early evaluation of kidney disease (SEEK) study, the overall prevalence of CKD stands at 17.2%; and, approximately 6% for CKD stage 3 and beyond. Hypertension and diabetes are the leading causes of CKD in India. As India moves to be the next diabetic capital of the world, it is expected that the number of CKD patients will rise.
CKD is known to be associated with increased social and psychological problems. Life-long treatment, recurrent symptoms, diet restriction, the high cost of treatment, deprived kidney function over time, and limited capacity to work are some of the factors that alter the daily lifestyle and social functioning. Unaffordable treatment is very common. In the absence of insurance coverage, patients pay out of their pocket., High cost of medication(s) is associated with medication nonadherence. Patients with depression are reported to have poor outcomes and poor the quality of life.
Depression is one of the most commonly occurring psychiatric problems in CKD patients. Prevalence of depression via questionnaire in patients or clinicians varies from 7%–50%. Most of the available evidence is from the western countries and in patients on dialysis. Until date, the prevalence of depresssion in CKD patients in India has not been evaluated. Chiang et al have reported advanced stages of CKD, gender, marital and living status, religious belief, sleep disturbance, and regular exercise are some of the responsible factors for depression in Taiwanese CKD patients.
Beck depression inventory (BDI), Hamilton Depression Scale (Hamilton), Patient Health Questionnaire-9 (PHQ-9), Hospital Anxiety and Depression Scale (HADS), and Center for Epidemiological Studies Depression Scale were some of the validated questionnaires to study the depression. PHQ-9 is validated, in the Hindi language, and freely available tool for academic research to study the depression in Indian patients.
Depression remains undiagnosed and untreated in the CKD patients. The routine screening and diagnosis help in decreasing this burden and improving patient’s quality of life. The aim of this study is to determine the prevalence of depression in patients with CKD and the factors affecting it at a public tertiary care hospital.
| Methods|| |
This cross-sectional study was carried out at a public teaching tertiary care hospital in Chandigarh from September 2014 to April 2016 at the renal clinic of a tertiary care hospital.
Patients of either gender aged 18 years or above diagnosed with CKD and receiving treatment, and willing to participate were included in the study. Patients with cognitive impairment, critically ill, not willing to participate or unable to complete the interview were excluded from the study.
The study was approved by Government Medical College and Hospital (GMCH), Chandigarh Human Ethics Committee and carried out in compliance with the ethical guideline provided by ICMR for such studies.
Patients’ confidentiality was respected. Patients were informed about the objectives of study and procedure. When the patients agreed to participate, informed consent was obtained for participation. Questionnaire response from the patients was collected via patient interview by a research investigator. Patients were also informed that they could withdraw from the study at any time and they will continue to receive the same level of care as other patients.
Socio-demographic, anthropometric details and clinical variables were recorded in a data collection form via patient interview and details in OPD card. Patients’ clinical record was used for collecting clinical details.
PHQ-9 is a validated tool to assess the depression. It has been used and validated in Indian patients. It consists of nine questions to assess the depression. Each question score ranging from 0–3 (maximum score-27). The depression was furthered classified on the basis of score “minimal” to “severe” depression. Score 0–4 were considered as “minimal;” 5–9 as “mild;” 10–14 as “moderate;” 15–19 as “moderately severe” and 20–27 as “severe” depression.
Internal consistency of PHQ-9 in Indian CKD patients was assessed by using Cronbach’s alpha (α). The Cronbach’s α in this study was 0.92, indicates a good internal consistency of PHQ-9 in this population.
Modified Kuppuswamy’s scale was used to assess the patients’ socioeconomic status. It classifies the patients into five classes on the basis of occupation, patients’ education, and family monthly income.
Kidney Disease Improving Global Outcomes guidelines were used to define and classify CKD. Patients were classified on the basis of glomerular filtration rate (GFR) and albuminuria. The Cockcroft-gault equation was used for calculation of creatinine clearance.
Patients were classified into different Body Mass Index (BMI) categories according to the World Health Organization Global database on BMI. The patients with 60 years of age or beyond were defined as “elderly.”
Descriptive and inferential statistics were used. Patients’ age, weight, disease duration, and biochemical data were expressed as mean with standard deviation (SD). Categorical variables such as gender, age group categories, CKD stages, comorbidities, and income were represented using percentage. Chi-square test and one-way analysis of variance for continuous variables were used to explore the relationship between the depression and other variables. Various factors that determine the prevalence of depression were assessed by using multiple logistic regression analysis. Predictors were represented using the OR and 95% confidence intervals and P<0.05 was considered as statistically significant. Strengthening the Reporting of Observational Studies in Epidemiology statement for cross-sectional studies were used for reporting.
| Results|| |
A total of 612 patients were included and interviewed with a response rate of 96% (612/635).
The mean age of the patients was 54.3 years and 53% of them were male. Thirty-six percent of the patients were elderly. Moreover, 31% and 34% were found to be smoker and alcoholic, respectively. Over one-fourth of the patients were receiving the treatment funding (27%) whereas 73% of the patients paid out of pocket. Of the total, 47% of the patients were unemployed/retired and 15% had attended school only up to eight standard. Among total patients, 66% were residing in the urban area and only 36% had monthly income over INR 20,000. Socioeconomic status classification of the patients revealed that the maximum number of the patients belonged to middle class followed by upper and lower class, respectively (59%, 23%, and 19%; [Table 1]).
|Table 1: Sociodemographic characteristic of the chronic kidney disease patients on the basis of the presence of depression.|
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The patients were classified by GFR. About 39% of them were in CKD stage V, 28% were on hemodialysis (HD), and 41% were diagnosed with CKD for >2 years.
Among the enrolled patients, 38% were found to have at least three or more comorbidities. Fifty-three percent had hypertension, 39% had diabetes, 32% had hyperlipidemia, and 46% of patients had anemia.
BMI classification revealed that 36% of the patients were overweight [Table 2]. The median (IQR) BMI of the patients was 24.1 (20.3–28.5). The median (IQR) duration of CKD, diabetes, hypertension was found to be 2 (16), seven (1–11), and 10 (3–19), respectively.
|Table 2: Clinical characteristics of the patients with chronic kidney disease by PHQ 9 score.|
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The overall prevalence of depression in this study was 44.1%. The mean (SD) score of depression was 7.1 (3.5). The patients were classified by the PHQ-9 score into none, mild, moderate, moderately severe, and severe depression. Of the 612 patients, 342 did not report any sign of depression, but 28.4% of the patients were found to have mild depression, 11.8% had moderate, 3.1% had moderately severe, and only 0.8% of patients had severe depression.
The prevalence of depression was evaluated across different sociodemographic variables and found statistically significantly different across gender, age, alcoholic, treatment reimbursement, employment, residence area, and socioeconomic status of the patients [Table 1].
Further, depression was classified by clinical characteristics of the patients; and, it was found statistically significant different across stages of CKD, duration of CKD, patients’ HD status, comorbidities, the presence of hypertension, duration of hypertension, the presence of diabetes and duration of diabetes, the presence of hyperlipidemia, anemia, and different BMI categories [Table 2].
Gender, age, treatment funding, education, monthly family income, CKD stage, HD status, existing comorbidities, BMI, and duration of CKD was found to be statistically significant predictors for the occurrence of depression in CKD patients using multivariable regression model [Table 3].
|Table 3: Statistically significant predictors of depression in CKD using multivariate logistic regression.|
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| Discussion|| |
Globally, most of the patients with chronic kidney disease is known to have depression. The reasons for this are an increasing number of comorbidities, financial burden due to disease, and lifelong diagnosis and treatment of CKD. CKD treatment over a period leads to a loss in terms of health, wealth and status of the patients and family. To the best of authors’ knowledge, this is the first report to evaluate the prevalence and predictors of depression in Indian CKD patients.
The mean age of the CKD patients according to the first report of Indian CKD registry was found slightly lower on compared to the present study (50.1 and 54.3 years, respectively). According to the registry, 70.3% of the patients were male (53%, in the present study). Monthly family income, as per the registry, was less than INR 20,000 in 20.5% of the patients and in the current study, this was 64%. Rajapurkar et al reported 48.1% of the patients in CKD stage V; and, in our study, this was 39% only. Single site of the present study may be one of the reasons for this variation. In the present study, 66% of the patients were residing in urban regions com-pared to 73.4% in SEEK study.
SEEK study reported hypertension and diabetes to be the most common comorbidities (64.5% and 31.6%, respectively). These findings were found comparable to the present study which reported hypertension and diabetes in 53% and 39% of the patients, respectively. According to SEEK and START studies, 31.6% and 41.2% of the patients, respectively were found overweight (compared to 36% in the present study.,
In the present study, 44.1% of the patients were found to be depressed. The prevalence was found higher than that of study carried out by Andrade et al (using the BDI questionnaire- 37.3%), Amira et al (using Zung depression questionnaire - 23.7%), Balogun et al (using PHQ - 30%), Chiang et al (using Taiwanese Depression questionnaire - 22.6%), and Yu et al (using PHQ - 19.9%)., According to study carried out by Al-Zaben et al, the prevalence of depressive disorder was 6.8% (major - 3.2%, minor - 3.6%), and significant depressive symptoms were present in 24.2%.
Prevalence of depression was found lower than that of the study carried out by Makara- Studzmska et al (using BDI - 66%) ; Tanvir et al (using HADS - 57%); Bossola et al (using BDI - 52.5%); Lee et al (using HADS - 47%).,,, Over 50% of the patients were found depressed according to the study carried out by Macaron et al.
The higher prevalence of depression in the present study may be due to use of different tool to assess the depression. Further, the financial burden associated with HD therapy in India and the fact that the cost of treatment is entirely borne by the patients and their family. In addition, loss of patient’s job, loss of wages and time of the family members due to illness, the severity of disease, the presence of several comorbidities, and fear of death. All of these factors might be contributing to increased prevalence of depression in CKD patients.
The findings of the present study suggest that the depressive symptoms increased with increase in the duration of CKD. Amira et al and Hedayati et al have reported similar findings in CKD patients.,
In the present study, patients with end stage renal disease (ESRD) on dialysis were more likely to be depressed when compared to those not on dialysis. These findings were consistent with the results of Amira et al that also suggested that patients on dialysis are at higher risk of depression in comparison to those not on dialysis. Watnick et al showed that there is no difference in the prevalence of depression among predialysis and ESRD patient. Similarly, the prevalence of depression was found similar to that reported by Abdel-kaber et al in ESRD patients on HD and CKD stage IV and V patients not on HD, using PHQ.
Younger age group (≤60 year s) was found to be a significant risk factor for the depression in CKD patients. These findings were found to be consistent with the findings of Yu et al using PHQ in ESRD patients.
| Strengths and Limitations|| |
The key strengths of the study were high response rate, large sample size, and patients from different socioeconomic status and with different clinical characteristics. Data were collected from patients’ medical record with self-reports, to decrease the chances of missing.
There were chances of reporting bias in the study as the patients were interviewed for the presence of depression. Due to the crosssectional nature of study, a causal relationship between the occurrence of depression and CKD could not be established. In the absence of a similar study in Indian healthcare setting, findings could not be compared.
| Conclusion|| |
From the findings of the current study, it can be concluded that close to half of the CKD patients (44.1%) attending the outpatient renal clinic of a tertiary care public teaching hospital suffer from depression. Patients’ age, gender, BMI, treatment funding, education level, income, CKD duration and stage, HD status, and existing comorbidities were found to be significant predictors. Therefore, an early diagnosis of depression could be helpful in improving the quality of life of CKD patients.
| Acknowledgment|| |
We would like to thank Prof. Atul Sachdev, Director Principal, GMCH, Chandigarh, India, for his support in conducting the study. We also like to thank, Prof. Sarabmeet S. Lehl, GMCH, Chandigarh for his support in study planning.
Conflict of interest: None declared.
| References|| |
Ahlawat R, Tiwari P, D’Cruz S, Singhal R. Prevalence of chronic kidney disease in India: A systematic review and meta-analysis of observational studies. Value Health 2015;18: A509.
Singh AK, Farag YM, Mittal BV, et al. Epidemiology and risk factors of chronic kidney disease in India – Results from the SEEK (Screening and Early Evaluation of Kidney Disease) study. BMC Nephrol 2013; 14:114.
Rajapurkar MM, John GT, Kirpalani AL, et al. What do we know about chronic kidney disease in India: First report of the Indian CKD registry. BMC Nephrol 2012;13:10.
Ahlawat R, Tiwari P, D’Cruz S. Cost of illness and the factors affecting it in the patients of chronic kidney disease at a public tertiary care hospital. Value Health 2015;18:A187-8.
Ahlawat R, D’Cruz S, Tiwari P. Drug utilization pattern in chronic kidney disease patients at a tertiary care public teaching hospital: Evidence from a cross-sectional study. J Pharma Care Health Sys 2015;3:149.
Ahlawat R, Tiwari P, D’Cruz S. Prevalence and predictors of medication non-adherence in patients of chronic kidney disease: Evidence from a cross sectional study. J Pharma Care Health Sys 2016;3:152.
De Sousa A. Psychiatric issues in renal failure and dialysis. Indian J Nephrol 2008;18:47-50.
] [Full text]
Palmer S, Vecchio M, Craig JC, et al. Prevalence of depression in chronic kidney disease: Systematic review and meta-analysis of observational studies. Kidney Int 2013;84:179-91.
Chiang HH, Livneh H, Yen ML, Li TC, Tsai TY. Prevalence and correlates of depression among chronic kidney disease patients in Taiwan. BMC Nephrol 2013;14:78.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA 1999;282:1737-44.
Kochhar PH, Rajadhyaksha SS, Suvarna VR. Translation and validation of brief patient health questionnaire against DSM IV as a tool to diagnose major depressive disorder in Indian patients. J Postgrad Med 2007;53:102-7.
] [Full text]
Bairwa M, Rajput M, Sachdeva S. Modified Kuppuswamy’s Socioeconomic Scale: Social researcher should include updated income criteria, 2012. Indian J Community Med 2013; 38:185-6.
] [Full text]
Prasannakumar M, Rajput R, Seshadri K, et al. An observational, cross-sectional study to assess the prevalence of chronic kidney disease in type 2 diabetes patients in India (START - India). Indian J Endocrinol Metab 2015;19: 520-3.
Amira O. Prevalence of symptoms of depression among patients with chronic kidney disease. Niger J Clin Pract 2011;14:460-3.
] [Full text]
Balogun RA, Abdel-Rahman EM, Balogun SA, et al. Association of depression and antidepressant use with mortality in a large cohort of patients with nondialysis-dependent CKD. Clin J Am Soc Nephrol 2012;7:1793- 800.
Yu MK, Weiss NS, Ding X, Katon WJ, Zhou XH, Young BA. Associations between depressive symptoms and incident ESRD in a diabetic cohort. Clin J Am Soc Nephrol 2014; 9:920-8.
Al Zaben F, Khalifa DA, Sehlo MG, et al. Depression in patients with chronic kidney disease on dialysis in Saudi Arabia. Int Urol Nephrol 2014;46:2393-402.
Makara-Studzińska M, Koslak A. Depression symptoms among patients with end stage renal disease and among primary health care patients. Arch Psychiatry Psychother 2011;3:5-10.
Tanvir S. Prevalence of depression and anxiety in chronic kidney disease patients on haemodialysis. Ann Pak Inst Med Sci 2013;9:64-7.
Bossola M, Ciciarelli C, Di Stasio E, et al. Correlates of symptoms of depression and anxiety in chronic hemodialysis patients. Gen Hosp Psychiatry 2010;32:125-31.
Lee YJ, Kim MS, Cho S, Kim SR. Association of depression and anxiety with reduced quality of life in patients with predialysis chronic kidney disease. Int J Clin Pract 2013;67:363-8.
Macaron G, Fahed M, Matar D, et al. Anxiety, depression and suicidal ideation in Lebanese patients undergoing hemodialysis. Community Ment Health J 2014;50:235-8.
Hedayati SS, Minhajuddin AT, Afshar M, Toto RD, Trivedi MH, Rush AJ. Association between major depressive episodes in patients with chronic kidney disease and initiation of dialysis, hospitalization, or death. JAMA 2010;303:1946-53.
Watnick S, Kirwin P, Mahnensmith R, Concato J. The prevalence and treatment of depression among patients starting dialysis. Am J Kidney Dis 2003;41:105-10.
Abdel-Kader K, Unruh ML, Weisbord SD. Symptom burden, depression, and quality of life in chronic and end-stage kidney disease. Clin J Am Soc Nephrol 2009;4:1057-64.
Prof. Pramil Tiwari
Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research, Mohali, Punjab
[Table 1], [Table 2], [Table 3]